Pat Posa RN, BSN, MSA Kimberly O’Brien, MHASystem Performance Improvement Leader Director, Program DevelopmentSt. Joseph Mercy Health System Missouri Center for Patient SafetyAnn Arbor, MI Jefferson City, MOpatposa@comcast.net kobrien@mocps.org

Coaching Call 6: An Introduction to Teamwork & Communication Tools

June 19, 2012

Document 1

THEBASICS OF CUSP

Documents for Coaching Call 6

1. Coaching Call 6 Presentation (this document)2. Coaching Call 6 Team Leader Monthly Checklist3. Sample Agenda for Team meeting 5 or 64. Article: Impact of a Statewide Intensive Care Unit

Quality Improvement Initiative on Hospital Mortality and Length of Stay

5. Article: The Effect of Multidisciplinary Care Teams on Intensive Care Unit Mortality

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Before We Get Started . . . A Brief Recap of Coaching Call 5

(5/15/2012)• Step 2 of CUSP: Measure Unit Culture – HSOPS Results• Step 5 of CUSP: Learn from one Defect per Quarter –

Learning from a Defect Tool & Case Summary Form• Coaching Call 5 Team Leader Checklist

– Complete action items from Coaching Call 4– Facilitate team meeting 4 or 5– Work through the Learning from a Defect Tool– Begin action planning with HSOPS or other patient safety survey

results

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The “Secret Ingredient”Comprehensive Unit-Based Patient

Safety Program1. Form a unit CUSP team with executive

sponsorship2. Measure unit culture3. Educate staff on Science of Safety4. Identify defects using the Staff Safety

Assessment; prioritize defects5. Learn from one defect per quarter6. Implement team/communication tools

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Step 6: Implement

Team/communication tools

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• Effective communication amongst caregivers is essential for a functioning team

• The Joint Commission reports that ineffective communication is the most commonly cited cause for a sentinel event

• Observations of ICU teams have shown errors in the ICU to be concentrated after communication events (shift change, handoffs, ect)

• 30% of errors are associated with communication between nurses and physicians

Reader, CCM 2009 Vol 37 No 5; Donchin CCM 1995 Vol 23

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• Structured Communication

• Assertion/Critical Language

• Psychological Safety

• Effective Leadership

• SBAR, structured handoffs

• Key words, the ability to speak up and stop the show

• An environment of respect

• Flat hierarchy, sharing the plan, continuously inviting other team members into the conversation, explicitly asking people to share questions or concerns, using people’s names

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• Daily rounds/goals• Huddles• Handoff standardization• Pre-procedure briefing• Morning briefing• Executive Safety Rounds/Partnership• Learn from a defect

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The Effect of Multidisciplinary Care Teams on Intensive Care Unit Mortality

Arch Intern Med Feb 22, 2010

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• Retrospective cohort study (using state discharge data from Pennsylvania Health Care Cost Containment Council)

• 112 hospitals• Non-cardiac, non-surgical ICUs• 30 day mortality• Looked at 3 types of multidisciplinary care models

•multidisciplinary care staffing alone•intensivist physician staffing alone•interaction between intensivist physician staffing

and multidisciplinary care teams

The Effect of Multidisciplinary Care Teams on Intensive Care Unit Mortality

Arch Intern Med Feb 22, 2010

Association Between Intensivist Physician Staffing and 30-Day Mortality for All Patients

Variable OR (95% CI) P Value

Model 1: multidisciplinary care staffing alone– No multidisciplinary care 1 [Reference]

– Multidisciplinary care 0.84 (0.76-0.93) .001

Model 2: intensivist physician staffing alone– Low intensity 1 [Reference]– High intensity 0.84 (0.75-0.94)

.002

Model 3: interaction between intensivist physician staffing and multidisciplinary care teams

– Low intensity+ no multidisciplinary team 1 [Reference]– Low intensity + multidisciplinary team 0.88 (0.79-0.97) .01– High intensity + multidisciplinary care 0.78 (0.68-0.89) .001

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• Purpose: Improve communication among care team and family members regarding the patient’s plan of care

• Goals should be specific and measurable• Documented where all care team members have access• Checklist used during rounds prompts caregivers to focus on what needs to be

accomplished that day to safely move the patient closer to transfer out of the ICU or discharge home

• Measure effectiveness of rounds—team dynamics, communication

Interdisciplinary rounds with daily goals

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• Should be done in ICUs and all units in hospital• Hard initiative to implement, especially if you have an open unit and/or no intensivists or in non-ICU area

– Standardize the structure and process for all units– Benefits seen even if physician can not attend consistently or at all– Second rounds should be done in afternoon—include at least physician and bedside nurse

• Evaluate if goals for day have been met; readjust if necessary• Identify if patient can be discharged (or transferred ) the next day and if so, what needs to be accomplished

• Focused first on defining daily goals and recording those either on the white board in the room or on a sheet of paper

• Then standardize rounds—who should attend and what is discussed• Implemented nursing objective card—to clearly define role of nurse in interdisciplinary rounds

Interdisciplinary rounds with daily goals---Challenges and Opportunities

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Nursing Card

VAP

DeliriumSepsis

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• Enable teams to have frequent but short briefings so that they can stay informed, review work, make plans, and move ahead rapidly.

• Allow fuller participation of front-line staff and bedside caregivers, who often find it impossible to get away for the conventional hour-long improvement team meetings.

• They keep momentum going, as teams are able to meet more frequently.

Huddles

Use this strategy to begin to recovery immediately from defects---IE: falls, sepsis and daily to focus on unit outcomes

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Components

Metric 1: Quality/SafetyMetric 2: Patient SatisfactionMetric 3: Operations

Daily Critical Communications

Information

Ideas in Motion

How to do it?

•Beginning or mid shift•5 minutes•Lead by member of unit leadership team

RN-RN Shift Handoff ChecklistS (Situation)• Reason for admission• Contact Information• Allergies• Current attending/resident

B (Background)• Status of advanced directives/ code status• Pertinent medical history• Brief overview of hospital/ICU course• Labs: abnormals this shift and pending or to do next shift• Tests/procedures: current shift and anticipated for next shift• Current Problems: medical and nursing

A (Assessment)• VS/pain past 24hours/shift• Neuro• CV• Respiratory• GI/GU (include I and O)• Skin• Mobility• Patient safety issues-current and anticipated• Medication concerns and updates

R (Recommendation)• Pending/anticipated tests and procedures• Other concerns• Current and anticipated family issues• Pending patient/family education needs• Status of current shift goals/problems• Anticipated Goals/problems for next shift• Other TO DOs/ Do you have any questions?• Patient/Nurse introduction• Joint review of lines/drips, neuro check etc.

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Transitions in care: Handoffs

Pre-procedure briefing• Make introductions• Discuss patient information and procedure• Agree upon a time for line insertion• Review best practice for line insertion (if necessary)• Nurse defines their role to physician: provide equipment,

monitor patient, provide patient comfort, observe for compliance with best practices and STOP procedure if sterile process compromised• Establish communication expectation for sterile procedure

breaks• Examples include: your sleeve has touched the IV pole, the

guide-wire touched the headboard• Identify any special supply or procedural needs• Discuss any special patient issues (IE: patient confused, patient

awake)• Answer any additional questionsTIME OUT: RIGHT PATIENT---RIGHT PROCEDURE

Used this when rolled out CLABSI bundle to non-ICU17

• Purpose: Increase communication between physicians and nursing staff while efficiently prioritizing patient care delivery and ICU admissions and discharges

• What is it? – A morning briefing is a dialogue between 2 or more

persons using concise and relevant information to promote effective communication prior to rounds

Morning Briefing

Have used this for a long time between charge nurses from shift to shift. Since we have closed the units, now this also occurs with charge nurse

and intensivist.

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• Tool: answer following questions– What happened overnight that I need to know about?– Where should I begin rounds? (patient that requires

immediate attention based on acuity)– Which patients do you believe will be transferring out

of the unit today?– Who has discharge orders written?– How many admissions are planned today?– What time is the first admission?

Morning Briefing

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Evidence: Over time results indicate that…

• Safety climate improves overall• Perceptions of management improve overall• Magic number for exposure of staff ≥ 60%

having participated in at least one per year• Nurse managers and charge nurses become

more realistic (their safety climate scores actually decrease), while physicians, nurses, RTs, nurses aides, etc, improve.

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Caregiver Roles Pre-Post EWR

Adapted from:Frankel et al. HSR (2008)

RNs improve over time, while Nurse Managers/Charge Nurses recalibrate

Impact of a statewide intensive care unit qualityimprovement initiative on hospital mortality and

length of stayBMJ, February 2011

Method• Retrospective comparative analysis• Study period: October 2001 to December 2006• Study sample: all hospital admissions with an ICU stay for

adults age 65 or older at hospitals with 50 or more acute care beds and 200 or more admissions to the ICU during that time period

• 95 study hospitals in Michigan compared with 364 hospitals in surrounding Midwest region

• Look at hospital mortality and length of hospital stay

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Impact of a statewide intensive care unit qualityimprovement initiative on hospital mortality and

length of stayBMJ, February 2011

Results: Odds ratio for mortality in Michigan and comparison hospitals

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Study group Comparison group

P value

Pre-Implementation

0.98(0.94 to 1.01) 0.96 (0.95 to 0.98) 0.373

Post-Implementation1-12 months

0.83 (0.79 to 0.87) 0.88 (0.85 to 0.90)

0.041

Post-Implementation13-22 months

0.76 (0.72 to 0.81) 0.84 (0.81 to 0.86) 0.007

What are your next steps?

Finish Learn from a Defect summaryCreate action plan for HSOPSChose one teamwork or

communication tool to implement over next 3 months

Celebrate your successes!!!

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Module 1: The Basics of CUSP• Session 1: Forming a CUSP team and

Science of Safety Education• Session 2: Staff Safety Assessment and

Measuring Culture• Session 3: Learning from a Defect-part 1• Session 4: Learning from a Defect-part 2• Session 5: Safety Culture Results and

Action Planning• Session 6: Teamwork & Communication

Tools

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Be Courageous

We all are responsible for the safety of our patients----Own the issues

•“If not this, then what??”•“If not now, then when?”•“If not us, then who??”

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Notes on Hospitals: 1859

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

Florence Nightingale

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Advocacy = Safety

A Healthcare Imperative

“In medicine, as in any profession, we must grapple with systems, resources, circumstances, people-and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, we must improve.”

Atul Gawande in his book, Better: A Surgeon’s Notes on Performance

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Questions?

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